Otezla (apremilast) Page 1 of 7 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Otezla (apremilast) Prime Therapeutics will review Prior Authorization requests Prior Authorization Form: https://www.bcbsks.com/customerservice/forms/pdf/priorauth-6343ks-otez.pdf Link to Drug List (Formulary): https://www.bcbsks.com/drugs/ Professional Institutional Original Effective Date: January 1, 2017 Original Effective Date: January 1, 2017 Revision Date(s): January 1, 2017; October 1, 2017; October 15, 2017; January 26, 2018 Revision Date(s): January 1, 2017; October 1, 2017; October 15, 2017; January 26, 2018 Current Effective Date: January 26, 2018 Current Effective Date: January 26, 2018 State and Federal mandates and health plan member contract language, including specific provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. To verify a member's benefits, contact Blue Cross and Blue Shield of Kansas Customer Service. The BCBSKS Medical Policies contained herein are for informational purposes and apply only to members who have health insurance through BCBSKS or who are covered by a self-insured group plan administered by BCBSKS. Medical Policy for FEP members is subject to FEP medical policy which may differ from BCBSKS Medical Policy. The medical policies do not constitute medical advice or medical care. Treating health care providers are independent contractors and are neither employees nor agents of Blue Cross and Blue Shield of Kansas and are solely responsible for diagnosis, treatment and medical advice. If your patient is covered under a different Blue Cross and Blue Shield plan, please refer to the Medical Policies of that plan.
Otezla (apremilast) Page 2 of 7 DESCRIPTION The intent of the Otezla (apremilast) Prior Authorization with Quantity Limit criteria is to ensure that patients prescribed therapy are properly selected according to Food and Drug Administration (FDA)-approved product labeling and/or clinical guidelines and/or clinical trials. The criteria will encourage the use of first-line conventional agents. Target Drugs Otezla (apremilast) FDA Approved Indications and Dosage 1 Otezla (apremilast) is indicated for the following: Treatment of adult patients with active psoriatic arthritis Treatment of patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy The recommended initial dosage titration of Otezla from Day 1 to Day 5 is shown in Table 1. Following the 5-day titration, the recommended maintenance dosage is 30 mg twice daily taken orally starting on Day 6. This titration is intended to reduce the gastrointestinal symptoms associated with initial therapy. Otezla can be administered without regard to meals. Do not crush, split, or chew the tablets. Table 1: Dosage Titration Schedule Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 AM AM PM AM PM AM PM AM PM AM PM 10 mg 10 mg 10 mg 10 mg 20 mg 20 mg 20 mg 20 mg 30 mg 30 mg 30 mg POLICY Prior Authorization and Quantity Limits Criteria for Approval Initial Evaluation 1. The patient has a diagnosis of ONE of the following: a. Moderate-to-severe plaque psoriasis and ONE of the following: i. There is documentation that the patient is currently being treated with the requested agent (starting on samples is not approvable) ii. The prescriber states the patient is using the requested agent (starting on samples is not approvable) is at risk if therapy is changed
Otezla (apremilast) Page 3 of 7 iii. iv. The patient s medication history indicates use of a biologic immunomodulator agent for the same FDA labeled indication The patient s medication history indicates use of one conventional agent prerequisite v. The patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to at least ONE conventional agent b. Active psoriatic arthritis ONE of the following: i. There is documentation that the patient is currently being treated with the requested agent ii. iii. iv. The prescriber states the patient is using the requested agent is at risk if therapy is changed The patient s medication history indicates use of a biologic immunomodulator agent for the same FDA labeled indication The patient s medication history indicates use of one conventional agent prerequisite v. The patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to at least ONE conventional agent c. Another FDA labeled indication 2. The patient is not currently being treated with a biologic immunomodulator agent 3. The patient does not have any FDA labeled contraindication(s) to therapy with the requested agent 4. ONE of the following: a. The prescribed dosage is within the program limit (FDA approved labeled dosage) b. The quantity (dose) requested is greater than the maximum dose recommended in FDA approved labeling, and the prescriber has submitted documentation in support of therapy with a higher dose for the intended diagnosis which has been reviewed and approved by the Clinical Review pharmacist Length of approval: 12 months
Otezla (apremilast) Page 4 of 7 Renewal Evaluation Otezla (apremilast) will be approved for renewal when the following criteria are met: 1. The patient has been previously approved for therapy through Prime Therapeutics PA process 2. The patient has shown clinical improvement (i.e. slowing of disease progression or decrease in symptom severity and/or frequency) 3. The patient does not have any FDA labeled contraindication(s) to therapy with the requested agent 4. The patient is not currently being treated with a biologic immunomodulator agent 5. ONE of the following: a. The prescribed dosage is within the program set limit (FDA approved labeled dosage) b. The quantity (dose) requested is greater than the maximum dose recommended in FDA approved labeling, and the prescriber has submitted documentation in support of therapy with a higher dose for the intended diagnosis which has been reviewed and approved by the Clinical Review pharmacist Length of approval: 12 months Brand (generic) Otezla (apremilast) 10 mg, 20 mg & 30 mg tablet starter pack (two week) 10 mg, 20 mg & 30 mg tablet starter pack (4 week) 30mg tablets Quantity Limit 1 starter kit of 27 tablets/180 days 1 starter kit of 55 tablets/180 days 60 tablets/30 days Conventional Agent Prerequisites by Indication FDA Labeled Indications Conventional Agent Prerequisites Psoriatic arthritis () methotrexate leflunomide hydroxychloroquine minocycline sulfasalazine Psoriasis (PS) methotrexate topical corticosteroids coal tar products anthralin calcipotriene calcitriol acitretin tazarotene cyclosporine methoxsalen tacrolimus pimecrolimus PUVA (phototherapy)
Otezla (apremilast) Page 5 of 7 FDA Labeled Indications Included In This Program For Biologic Immunomodulators Target Agent FDA Labeled Indications Cimzia (certolizumab) Cosentyx (secukinumab) Enbrel (etanercept) Humira (adalimumab) Inflectra (infliximab-dyyb) Remicade (infliximab) Renflexis (infliximab-abda) Siliq (brodalumab) Simponi (golimumab) Stelara (ustekinumab) Taltz (ixekizumab) Tremfya (guselkumab) Xeljanz (tofacitinib) Xeljanz XR (tofacitinib) PS=psoriasis, =psoriatic arthritis Actemra (tocilizumab) Arcalyst (rilonacept) Cimzia (certolizumab) Cosentyx (secukinumab) Enbrel (etanercept) Entyvio (vedolizumab) Humira (adalimumab) Ilaris (canakinumab) Inflectra (infliximab-dyyb) Kevzara (sarilumab) Kineret (anakinra) Orencia (abatacept), PS, PS PS Contraindicated as Concomitant Therapy Remicade (infliximab) Renflexis (infliximab-abda) Rituxan (rituximab) Siliq (brodalumab) Simponi (golimumab) Simponi ARIA (golimumab) Stelara (ustekinumab) Taltz (ixekizumab) Tremfya (guselkumab) Tysabri (natalizumab) Xeljanz (tofacitinib) Xeljanz XR (tofacitinib extended release) Agent Otezla (apremilast) Contraindications Hypersensitivity to apremilast or any of the excipients RATIONALE Psoriasis and Psoriatic Arthritis (PsA) The American Academy of Dermatology guidelines state that 80% of psoriasis patients have limited disease involvement, typically defined <5% of body surface area, and can be effectively managed with topical agents such as corticosteroids, vitamin D analogues, tazarotene, etc. For more significant disease, biologics are utilized. 2
Otezla (apremilast) Page 6 of 7 Approximately 10-30% of patients with psoriasis will also have PsA. EULAR Recommendations on the management of psoriatic arthritis recommend the following 3 : Conventional synthetic DMARDs [(csdmards); i.e. MTX, sulfasalazine, leflunomide] should be considered in: Early stage peripheral arthritis, particularly in those with poor prognosis (i.e. swollen joints, structural damage in the presence of inflammation, high erythrocyte sedimentation rate/c reactive protein and/or clinically relevant extra-articular manifestations). MTX is preferred in those with relevant skin involvement After failure to at least one csdmard, therapy with a bdmard (usually TNF-i followed by bdmards targeting IL-12/23 or IL-17 if TNF-i is not appropriate) should be considered After failure to at least one csdmard, where a bdmard is not appropriate, a targeted synthetic DMARD (tsdmard), such as a PDE4-inhibitor should be considered In those with active enthesitis and/or dactylitis with failure to NSAIDs/local glucocorticoids injections, a bdmard should be considered (current practice is a TNF-i) Predominantly active axial disease: after failure to NSAIDs, a bdmard should be considered (current practice is a TNF-i) After failure to a bdmard, switch to another bdmard, including switching between TNFinhibitors Safety 1 Otezla is contraindicated in patients with a known hypersensitivity to apremilast or to any of the excipients in the formulation. REVISIONS 01-01-2017 Policy published 12-29-2016. Policy effective 01-01-2017. 10-01-2017 In Policy section: Removed "Biologic Agent" from the title of the "Biologic Agent Contraindicated as Concomitant Therapy" chart to read "Contraindicated as Concomitant Therapy" Added Kevzara (sarilumab), Renflexis (infliximab-abda), Siliq (brodalumab) and Tremfya (guselkumab) to the Contraindicated as Concomitant Therapy chart. Added an FDA Labeled Indications Included In This Program For Biologic Immunomodulators chart. 10-15-2017 In Policy section: In Item 1 a i and 1 a ii added "(starting on samples is not approvable)" to read, "i. There is documentation that the patient is currently being treated with the requested agent (starting on samples is not approvable)" ii. The prescriber states the patient is using the requested agent (starting on samples is not approvable) is at risk if therapy is changed" Added title of "Conventional Agent Prerequisites by Indication" to the Conventional Agent Prerequisites chart. References updated 01-26-2018 In Policy section: Updated FDA Labeled Indications Included In This Program For Biologic Immunomodulators chart adding new indication for Xeljanz XR.
Otezla (apremilast) Page 7 of 7 REFERENCES 1. Otezla Prescribing Information. Celgene Corporation. December 2015. 2. Menter A, Korman N, Elmets C, et al. Section 3. Guidelines of care for the management and treatment of psoriasis with topical therapies. J Am Acad Dermatol. 10.1016/j.jaad.2008.12.032 (epub February 2009). 3. Gossec, L. et al. European League Against Rheumatism (EULAR) recommendations for the management of psoriatic arthritis with pharmacological therapies: 2015 update. Ann Rheum Dis. December 2015.